ST. LOUIS COUNTY BOARD OF PLUMBING EXAMINERS 41 South Central 6th Floor St. Louis, Missouri 63105-1719
APPLICATION FOR EXAMINATION FEE $30.00 (payable to : St. Louis County Treasurer) 314-615-3741
This section must be completed or the application may not be processed. CHECK WHETHER YOU ARE APPLYING FOR LICENSE AS A: Master
Journeyman
CHECK LICENSE CATEGORY FOR WHICH YOU ARE APPLYING: (only one per application)
Plumber Sprinkler Fitter
Drainlayer (master only) Pipe Fitter Lawn Irrigation Installer Water Heater Specialist APPLICANT STATUS: New Applicant Re-Examination Expired License or Exam Credentials 1) Applicant Name____________________________________________ Date of Birth______-____-_______ 2) Social Security Number:_________/________/___________________ Home Phone__________________ 3) Home Address_________________________________________________________________________ Address
City
State
Zip
4) E-mail address: _______________________________________________________________________ 5) Employer Name____________________________________________ Employer Ph#_________________ 6) Employer Address_______________________________________________________________________ Address
City
State
Zip
7) Record of employment and experience with a bona fide contractor of above specified trade: (start with present or latest position held on line 1-you must provide verification of required experience) If additional space is needed you may attach a separate sheet of paper. YEARS From To
EMPLOYER NAME
EMPLOYER ADDRESS
EMPLOYER PHONE
8) IMPORTANT - If you have previously applied for a license in St. Louis County, Missouri indicate license for which applied and pertinent facts:
I hereby affirm the foregoing facts to be true to the best of my knowledge as I hereby make application for the license indicated above. Signature 1. 2. 3.
Date _____________________
Any misstatement or misrepresentation in said application will disqualify the applicant. The applicant will be notified in writing of the action of the board following his application. In the event an applicant fails to qualify for a license, the application fee deposited will not be refunded. If a new application for examination is s ubmitted, it must be accompanied by the fee specified by law.